The ‘New Normal’ Nursing

Entering the ninth month of what is deemed as the new normal, has reinforced the reality that COVID-19 has been the highlight of this year. Our lives have changed because of this pandemic. It became the decisive factor in several facets of our living. Lockdown was implemented more than once. For most of us, the year flew by like a blur.

One of the greatly affected sectors is healthcare. As the first few cases were confirmed in the British Isles, changes in rendering patient care were observed. It was a period of much uncertainty and anxiety. It was still a disease that we knew little about. Lots of questions needed answers. Policies changed as quickly as new information was disseminated.

In the neonatal unit, since we look after vulnerable patients, more precautionary measures have been set in place. Safety for everyone has always been a priority. Wearing masks and social distancing became mandatory. We also had to undergo fit testing for FFP masks in case a patient with COVID-19 will be placed in our care. The shift towards this new way of nursing was not easy. Having a mask on for 12 hours is not a comfortable experience and made communication slightly tricky, not to mention for the colleagues who had to don full PPE when caring for query COVID-19 babies. Some colleagues also had to self-isolate or shield. There were days when the supplies had to be carefully utilised.

The nurses, doctors and other healthcare team members were not the only ones who had to go through this trying time. It had been the same for parents as well- or probably even more than we believe. At the start, parents’ visiting hours and days were unfortunately greatly limited. Parent-child bonding is a pillar of neonatal care and the limitations brought about by the pandemic had been heart-breaking. But parents had been understanding and grateful that visiting was still possible in some way.

The doors to 24/7 visits may have temporarily been closed, but thanks to innovative and supportive people, our neonatal unit was provided with the vCreate app. This forward-thinking solution enabled nurses to connect the precious little ones with their parents through photos and videos. This has been a source of joy for many mums and dads, especially for those who do not live locally.

Outside of work, the first few months of lockdown was hard to get to grips with. Even grocery shopping was not as convenient as it used to be. Queues had been massive in some supermarket chains and necessities had been hard to come by. You begin to realise the many things that we had taken for granted. Despite these, it had been comforting to see and feel the public’s support for the NHS. I still remember the Clap for the NHS movement every Thursday evenings.

The virus knows no boundaries and it has affected us personally as well—there was news of colleagues, friends and families who were affected by COVID-19. Even an uncle of mine, unfortunately, succumbed to the disease. The tough part had been dealing with the reality my family is halfway across the world. Getting on a plane to the Philippines to be with and comfort them is no longer straightforward. Communication apps became even more essential- something which I could very much relate to with the babies’ families.
There is a light at the end of the tunnel though. Life has not gone back to ‘pre-COVID’ normality. But we are learning more about the virus and adapting accordingly. For the mums and dads of sick or premature babies, the good news is that they can now visit them any time, although separately.

The pandemic has no set end date, but rays of hope have been seen and hope is something that is very much needed.

Alicia Donovan, Enhanced Neonatal Nurse Practitioner (ENNP) University of Plymouth Hospital, England

When I was six, I had to have my tonsils removed. Since that day, I have always wanted to be a nurse. The sister who looked after me had such a kind face and manner, a crisp uniform with a hat and waist buckle belt. She made me feel like she cared, like I was worth her time and I looked up to her, I knew she was who I wanted to be.

Cut to February 2003, I’m starting my training to become an adult trained nurse. This wasn’t easy and it took me longer than I expected to get my Diploma, but when I finally achieved it, I was so proud. I had reached my life-long goal to date and was in for the long haul.

My first five years were spent in adult neuro intensive care. During this time, I cared for a pregnant lady with a brain injury, who went into preterm labour. After a c-section, the neonatal sister brought her new son down to visit whilst she was still sedated and on a ventilator. There was so much equipment on wheels – incubator, ventilator, pumps, you name it, it was there – but the sister was so calm, kind and baby oriented amidst the chaos. I did not know what was happening, but I was fascinated by this small baby nestling up to his mum’s chest to try to breast feed, mouth wide open. I asked the sister ‘any jobs going where you work?’.

After I finished my four nights with his Mum, I visited the NICU educator, enquiring about how to get a job. Low and behold a job became available a couple of weeks later and I jumped at the chance. Shortly after I left Neuro ICU to join NICU team.

Flash forward to March 2020. I have completed my special care module, QIS training, mentorship training, joined the transport service and became one of the first of 3 ENNPs at the University of Plymouth Hospital.

Then suddenly…COVID-19 starts to appear on the news. At first, I thought nothing of it, it’s just a bad case of flu. I’ve even had a strain of it before, and despite making my asthma flare up and landing me a short stint in hospital, I got over it and lived to tell the tale. Why should I be worried? I’m a nurse – I’ve been through worse.

Then the stories started to flood in. The risks to asthmatics were like nothing we’ve seen. I didn’t want to be a ‘vulnerable person’ but according to the news, GOV and risk assessments, that’s exactly what I am.

So now I am at home. Not working as nurse, transport or as an ENNP. Instead I am shielding to protect myself. This hits me hard, harder than I could possibly imagine, more than any the other issue I’ve have had to deal with. I’ve survived cancer, pregnancy loss, family loss, asthma. But COVID-19 knocks me down in a way I never expected. Since childhood, I have always helped, saved, cared for strangers and loved ones and now I can’t. I’ve got to do what lots of nurse’s struggle to do – care for myself, put myself first. I was not prepared for that.

Watching the news, reading about it online, hearing it all on the radio as I ‘worked from home’ made me feel guilty – guilty for not being able to help, guilty for not being part of the team (I was asked to return back to adult ITU to prepare and care for the potential patients that would arrive, but I couldn’t), guilty for not being there to support my co-workers, friends and family. The guilt was overwhelming and at week 6, I crumbled.

When I participated in the BAPM COVID-19 webinar, my emotions were running wild. I realised I needed support as all this was taking a toll on my mental health. I reached out to my line manager and the NICU Senior Sister, spoke to the mental health COVID-19 support team and I broke down – toxic guilt had taken over and I needed to open my eyes to the truth. The mental health team were amazing, set me back on track and made me see that I am still a nurse, will always be a nurse – as long as I look after myself. I had to let go of the guilt, I was not working but I was still saving lives and my own. I was not going to become a statistic; I wasn’t going to put the strain on the NHS and pressure on the ITU team and ONE day I will be able to return to my team back on NICU. I was honest with my manager and NICU sister, a small support group was created with our unit mental health support lead, allowing for others to speak up honestly and freely. The guilt it seems, was felt by us all and we were all adjusting to it differently. But together, we stayed safe, we stayed strong and we are still able to care, nurse and look after those who will need us when we come back.

So, I am at the start of week 15, completed many, many packages of e-learning, written some guidelines, attending meetings, REaSoN, completed Rotas, kept myself busy with tasks shared out by my colleagues who are still practicing. I have learned to forgive myself for not ‘nursing’, but I am still a nurse, now with more I.T and management skills then before and hopefully sometime soon, I can be back doing what I love the most.

COVID-19 might always be around, but so will nurses, ENNPs, ANNPs, doctors, physios, cleaners, cares, psychologists, occupational health, x-ray, managers, police, fire officers, the list goes on and on. For we are all part of one massive team, one massive family, always working together, saving lives and our own.

Working as a healthcare manager during COVID-19

I am the manager of a 45-bed single-family room Neonatal Intensive Care Unit (NICU) (Figure 1) in Halifax, Nova Scotia, Canada. Before becoming the manager of our unit, I was the clinical lead for our redevelopment to single rooms and was hugely influenced by the care models in Sweden, Norway and Estonia and had visited several of their NICUs to inform our design. I believe in family-integrated care with everything I have. I believe that NICU babies will have better outcomes when their parents are full participants in the care. Being a part of building our new unit, I never expected to have this deeply engrained belief challenged in the way that it was during the first wave of the COVID-19 pandemic.

FIGURE 1

We first felt the impact just before March break 2020. We busily did everything we needed to do to prepare for adequate personal protective equipment (PPE). N95 mask fittings were a priority but there was a shortage of masks and only a fraction of the NICU staff was fit tested. We also went through a very distressing time where some of the PPE was going missing. This required additional oversight to ensure that we had everything that would be required to keep the healthcare workers safe. We ran simulations for donning and doffing. We collaborated with one other health authority in the province. We asked our colleagues at other health centres across the country and even internationally what they were doing when it came to PPE. In the end, we felt ready.

While we were figuring out our PPE requirements, we were also creating clinical pathways to outline the care requirements of patients that were suspected or confirmed for COVID-19. This was a lot of work and the workload remained heavy for months. Our medical director (a Neonatologist) spent countless hours to ensure that our clinical pathways were evidence-based. Once he would have a suggestion, we would book time with our Infection Prevention and Control (IPAC) colleagues to gain their input. We often had to collaborate with other teams, such as obstetrics, postpartum, and transport to make sure that our pathways did not conflict with theirs. To this day he and I are often the first call whenever there is a question about the clinical care of a suspected COVID-19 patient as everyone knows that we are the ones that know these pathways inside out.

As a manager I needed to also make sure that the unit had staff. Things worsened throughout the second half of March with a state of emergency called on March 22nd. A provincial lockdown was in place. Anyone with signs of illness couldn’t come to work. All schools and childcare facilities were closed, and nurses needed to have their schedules adjusted. The one bright side was that everyone wanted to cancel their vacations which certainly helped as nurses became unavailable! It was another thing to worry about for sure.

There was so much fear during this time. None of us knew what was going to happen. One senior nurse in our unit came to me with tears in her eyes. She said, “I am actually angry at myself, that I am a nurse. I cannot believe that I am about to put my husband, my children, all of them at risk, all because of what I do for a living”. It was heartbreaking to see. Also breeding that fear was the decision by the hospital to house the pediatric pandemic response unit in our NICU. Patients were being admitted that were suspected of COVID-19 and there were NICU babies only a couple of rooms over. Some of the NICU babies were displaced to an open-bay ward to accommodate this decision. There was a high level of uneasiness all around.

March 23rd. The absolute worst day of all. The hospital decided that pediatric patients could only have one support person. I was the one that delivered this message to the NICU families. Dads looked at me with tears streaming down their face. Begging to stay. Telling me that they would never leave if they could only be there for their partner and baby. One Mom was so angry, “You have told me that I should lean on “my person”. He is my person and now you are saying that he cannot be here”. It was awful. Especially because I am the one that I told you about in the beginning, the one that believes in families being with their children, about the positive impact that has. I never thought that I would ever see the day when families could not be families. I cannot talk about that day without tearing up. I think a lot about the trauma that was caused. I think a lot about the damage that we caused. The weight of that one day is like no other.

The best things that came from the pandemic were the advancements in technology. Everything happened so fast! Getting certain staff to work from home, getting things in place for families to have a virtual connection in the absence of physical connections. And our hospital fed all the support people which was tremendous!

It has been a long nine months since this all began, and yet, we are so very lucky. The rates in our province have been relatively low. There was the creation of the Atlantic bubble in the summer that helped our community bonds grow. The pediatric pandemic response unit moved out of the NICU. A second support person was able to come back into the NICU which was the biggest win of all!! I yearn for the day when we are fully ourselves again. When the unit is filled with families. When we see siblings holding their new little family member. When the stress of this pandemic is lifted, and we can all breathe again.